Learning objective number seven, design a dysphagia evaluation and management program for your local hospital to improve quality of life and decrease aspiration pneumonia rates and readmission rates at your affiliated hospital. Dysphagia is a swallowing disorder with a prevalence estimated at 40 to 70 percent initially in acute stroke patients, but by one year post-stroke, the prevalence tends to decrease similar to bladder dysfunction at about 10 to 15 percent. It's more common in brainstem strokes, but it places patients at risk of dehydration, aspiration pneumonia, and malnutrition. There are three phases of swallowing, oral, pharyngeal, and esophageal. The most common cause of dysphagia is delayed pharyngeal phase. How do you evaluate a patient post-stroke with dysphagia? Predictors of aspiration include cough after swallow, dysarthria, dysphonia, abnormal gag reflex, a wet cough, and a wet voice. Evaluation should begin as soon as possible. Aspiration may be missed with a clinical bedside evaluation in stroke patients. Diagnosis can be made reliably by a modified barium video fluoroscopic swallow study by a qualified speech language therapist. In my view, this is a case where the gold standard is the test of choice. In recent years, flexible endoscopic evaluation of swallowing or phase has been done more commonly, and it can provide some anatomic information, including visualizing the vocal cords. Dysphagia management. In severely dysphagic patients, the recommendations may include NPO status with intravenous hydration and or a tube placement, either a nasogastric tube, a gastrostomy tube, or a jejunostomy tube. Yes, percutaneous endoscopic gastrostomy or PEG insertion is not without its risks, but the risks are relatively low. Otherwise, patients would be cleared to eat and drink, possibly with modified liquid-solid consistencies. It's important that patients and caregivers know that in almost all situations, these tubes are temporary. Many patients may be able to continue to eat and drink while they have a feeding tube to ensure their nutritional and hydration needs. Some therapy techniques include chin tuck when swallowing and head rotation, as well as oral motor exercises. There seems to be some role for thermal and or electrical stimulation to sensitize the swallowing reflex. Concluding objective number eight, determine the types of aphasia your patients have on your stroke unit. Post-stroke aphasia, which of course is a language impairment, may involve speaking, reading, writing, problem-solving, and gesturing. They tend to be subdivided into fluent aphasia and non-fluent aphasia. In non-fluent aphasia, patients cannot produce word fluency. In post-stroke aphasia, which is about 12% of cases, they can comprehend but cannot repeat or name. In global aphasia, which is about 32% of post-stroke aphasias, they cannot comprehend, repeat, or name. In transcortical motor aphasias, they can comprehend, repeat, and name. In transcortical mixed aphasias, they can repeat but cannot comprehend. In fluent aphasia, you can produce words. In phrase aphasia, you can't repeat, comprehend, or name. In transcortical sensory aphasia, you can repeat but cannot comprehend or name. In conduction aphasia, you can comprehend but you cannot repeat. And in anomic aphasia, you can comprehend and repeat but you cannot name. And this is a classification of aphasia types. And it's important to keep this in mind when evaluating patients at the bedside, in the outpatient setting. And you can generally have a good sense of what type of aphasia you have by checking for fluency, comprehension, repetition. How do you treat aphasia? With speech-language therapy, with various behavioral and linguistic techniques, intonation therapy, there seems to be some rule for constraint-induced movement therapy in aphasia treatment, and also medications, including promocryptine and fluoxetine. Question. Which characteristic predicts the least success in returning to work after a stroke? A. Aphasia. B. A high Barthol index score. C. A short rehabilitation length of stay. D. Middle cerebral artery distribution stroke. The answer is A, aphasia. Aphasia, independent of the side of hemiplegia, has been identified as a poor prognostic indicator for reemployment. Factors correlated with successful return to work after a stroke include age 55 or younger, previous professional managerial position, higher indication, household annual income greater than $30,000, a higher Barthol index score, and shorter rehabilitation lengths of stay. Anatomic location of the stroke is not predictive of reemployment potential, but severity of stroke, as demonstrated by specific functional deficits, had greater predictive ability. Other speech-language abnormalities post-stroke include dysarthria, apraxia, dysphonia, and debilia. Post-stroke depression is very common. It could be up to 80% of patients post-stroke. Post-stroke depression and even non-post-stroke depression can negatively impact function. Treatment should be considered for all patients. This should be probably a combination of psychotherapy and psychotropic medications, such as selective serotonin reuptake inhibitors or tricyclic antidepressants or other agents. Selective serotonin reuptake inhibitors, or SSRIs, also are thought to have motor recovery enhancement, perhaps by improvement in depression and or neuroplasticity. So this was the FLAME study in Lancet Neurology in 2011, a randomized placebo-controlled study. However, in Lancet in December 2018, in the FOCUS trial, they performed a double-blinded, randomized, placebo-controlled study of 20 milligrams daily of fluoxetine for six months, and it did not seem to improve functional outcomes. Disorders of arousal post-stroke, a frequency of 30% to 70%. You need to rule out medical etiology, such as infections, et cetera. Treatment is multifactorial. Medications can include methylphenidate, amantadine, modafinil, antidepressants, dextromethamine. However, the New England Journal article from Dr. Giacino in 2012 looked at amantadine in severe traumatic brain injury, not in stroke patients. Sexual dysfunction, a reported prevalence of 40% to 70%. Some patients report a significant decrease in libido, choidal frequency, arousal, and satisfaction. Physiatrists must talk with patients about sexuality. There are medical and psychological factors, including diabetes, cardiovascular disease, the use of beta blockers, and diuretics. Psychological factors in sexual dysfunction post-stroke include stigmatization, loss of subjective or objective attractiveness, fear of impotence, fear of recurrent stroke, fear of myocardial infarction, and depression. Treatment of sexual dysfunction should be comprehensive, addressing both the medical and the psychological factors. Medications can include phosphodiesterase E5 inhibitors or testosterone if no medical contraindications. There are also vacuum pump devices, and counseling is indicated. Functional recovery. Learning objective number nine, facilitate the return to work for your stroke outpatient with cognitive impairment and dysfunction. Vocational issues. Stroke can be devastating when it affects a patient who is still in the workforce at disease onset. For Black Schaefer in the Archives of Physical Medicine in 1990, about 50% of stroke patients were able to return to work, but negative factors include aphasia, severity of stroke, prior job satisfaction, social support, and mood. Referral to a vocational rehabilitation counselor is appropriate and recommended. This vocational rehabilitation counselor can meet with the patient, communicate with the employer, and provide job retraining if indicated and help protect the patient's rights, such as through the Americans with Disabilities Act. Stroke functional recovery. Approximately 30% required some assistance to walk, 25% required total assistance with activities of daily living, 35% had symptoms of depression, and 25% were in a skilled nursing facility. Within the first year post-stroke, hemiparesis tends to improve from 73% of patients to 37% of patients, aphasia from 36% to 20%, dysarthria from 48% to 16%, dysphagia from 13% to 4%, and incontinence from 29% to 9%. Question. In a patient with an anterior cerebral artery stroke, you would expect A, distal greater than proximal upper limb weakness, B, lower limb greater than upper limb weakness, C, upper and lower facial weakness, D, significant non-fluent aphasia. The answer is B, lower limb greater than upper limb weakness. The anterior cerebral artery, or ACA, supplies the anterior and medial frontal regions serving sensory-motor function of the leg, foot, and urinary bladder through its cortical branches. Ischemia in the anterior cerebral artery territory causes sensory-motor impairments involving the lower limb more than the upper limb, proximal arm more than the hand, with relative sparing of the face. Language is typically not disturbed. Stroke recovery. The sequence of recovery can stop at any stage. The degree of functional recovery is greater than that expected by a reduction in neurological impairments alone. Lacuna strokes generally have more favorable outcomes due to usual preservation of speech and cognition. Negative indicators for outcome prediction include advanced age, severity of stroke, prior stroke, urinary incontinence, bowel incontinence, visual-spatial deficits, hemi-intention, poor cognition, multiple neurological deficits, impaired sitting balance, poor social support, limitations in activities of daily living, depression, severe aphasia, severe medical comorbidities, coma ad nonsen, and absence of extensor thrust in the lower extremity. Acupuncture and stroke. Safe when used properly. It has been studied in motor recovery, post-stroke pain, post-stroke spasticity, and dysphagia. However, a Cochrane review in 2016 revealed very low evidence of acupuncture and stroke, and there is a substantial potential for a placebo effect. Hyperbaric oxygen post-stroke. It does not seem to be very helpful in stroke recovery, and there may be significant concerns for safety. Stem cell therapy post-stroke. A possibly promising therapy, but there is a dark side to stem cell therapy. Cannabis in stroke. Stroke is not on the diagnosis list for medical cannabis. It may work for spasticity, but beware of the side effects, particularly cognitive. CBD oil does not appear to be effective in stroke recovery. Conclusions. Stroke remains a common and disabling diagnosis. When utilizing a team approach led by physiatrists coordinating their medical and rehabilitative care, utilizing traditional and some emerging interventions, patients disabled by stroke should be in the best position to maximize their functional recovery. Thank you.

stroke management

dysphagia evaluation

aphasia treatment

multidisciplinary team

stroke recovery